OPERATIONS Flashcards
SURGICAL ISSUES ABDOMINAL TRAUMA
PRE Assess other injuries - intoxication Cspine stability CT prior to Sugery (OT vsRadiology) Monitoring - IAL Crossmatch (MTP)
INTRA RSI Modified Induction doses Surgery - laparotomy vs laparoscopy - damage control - permissive hypotension Coagulopathy
POST
- ICU/HDU
LIVER TRAUMA
AAST Liver Injury Scale Graded I - V 0 minor lacterations to avulsion from IVC .
Non Operative to Operative
- depends on grading
- Packs around liver 24-48hrs for haemostasis/correction coagulopathy
- Transfer specialist centre
- Consider Interverntional Radiology
High Grade injuries survival <10%
SPLENIC INJURY
CONSERVATIVE (MOST) - IF STABLE
RESECTION PARTIAL / TOTAL - UNSTABLE (RBC, peritonism)
IR Embolisation
Monitor in HDU/ICU
Need penicillin , immunised pneumococcus, H. Influenza
BARIATRIC SURGERY
Morbid Obesity >40 kg m2
Patient Characteristics
- Any age, Genders equal
- T2DM, IHD, Resp Disease, OSA
ISSUES PRE AIRWAY ASSESSMENT IV ACCESS - ultrasound - long cannulas. Assc conditions (T2DM, IHD, OSA)
INTRA Airway type - ETT Preoxygenation!! VENTILATION - ok if head up, IBW TV, PEEP RSI - Aspiration risk Positioning - Nerve Injury NMBD - Monitoring and reversal STAFF SAFETY - Manual handling, bed limits. Maintainence Des vs TIVA Analgesia - short acting , multimodal PONV
POST OP Analgesia - short acting Avoid PPC Risks of respiratory depression - monitoring VTE Prophylaxis
LAPAROSCOPIC COLORECTAL SURGERY
Anaesthesia Issues:
GA + ETT + Muscle Relaxantion
Hypercarbia+Acidosis due to CO2 abs from
pneumoperitoneum, long procedure, compromised ventilation in steep head down - may cause tachyarrthymias, HTN
STEEP HEAD DOWN Several Hours
- Increased VR - increased CO - caution patients with CCF or valvular heart disease
- Airway Migration - endobronchial
- Reduced FRC and TLV = atelectasis
- Increased risk of gas embolism
- Cerebral oedema
- Facial and airway oedema
- Cephalad spread of epidural
Difficult IV access (arms by side) - NIBP (surgeon pressing + long = IAL) - extensions
Conversion to open at any time
Post Op
Neuraxial vs PCA
LIVER RESECTION
- Hepatic Metastases
- Hepato Biliary Tumours ( benign and malignant)
- Trauma
- Organ donation
SURGERY
Initial - Liver mobilisation from peritoneal attachments
- Cholecystectomy
- Expose Vascular anatomy
Resection
- Potential for huge blood loss
- PRINGLE MANOEUVER - clamp hepatoduodenal ligament ( HA, PV, Cystic duct)
-Rarely need to clamp supra and infra hepatic IVC (note they only clamp 90%)
PREOP
Assess - Liver dysfunction, coagulaopathy
CVS/RESP (?will tolerate)
PERIOP
IAL + CVC (CVP)
TECHNIQUE ETT - Controlled Ventilation Thoracic Epidural (risk v benefit) CVP <5cm H20 (CVS Risks) - avoid fluids , vasoconstrictors
COMMUNICATION VITAL
ie. clamping, pneumothorax, blood loss
POST OP
Aim to Extubate
ICU
HERNIA
Protrusion of the whole or part of a viscus from its normal position through an opening in a wall of its containing cavity
ELECTIVE VS EMERGENCY (Acute abdomen)
Patient type - obese, older, pregnancy, chronic cough (COPD, asthma)
Extubation avoid coughing!
OBSTRUCTED OR PERFORATED ABDOMEN
Patient Type:
Any age ; older comorbidities (malignancy)
Systemically unwell with PAIN ++
Major fluid loss into bowel/peritoneal cavity (peritonitis)
Hypovolaemia - developing sepsis
PRE OP Comorbidities -CVS/RESP Hydration, Electrolytes Evidence of SHOCK FBS / Coags / UEC / Crossmatch ABC - MA - resus Look for AKI
URGENT but not emergent - resus prior to induction
Monitoring
IAL , +/- CVC. Temp
Anesthetic GA ETT RSI - probably no epidural ( go for rectus sheath) Large bore IV and IAL Aspirate NGT Fluid Warmers
Post Op
Likely HDU/ICU
Analgesia regional + PCA
Avoid NSAID
OESPHAGECTOMY
Different approaches depending on location of tumour and preference.
IVOR LEWIS =upper midline laparotomy followed by right thoracotomy (middle and lower third oesphagus(
THREE STAGE 0 Upper midline oesphagectomy ,
right thoracotomy and right/left cervical incisions ( tumours of upper and middle third)
PATIENT TYPE
ELderly
High alcohol and tobacco consumption
IHD COPD, may be malnourished
Pre OP STAGING TUMOUR ASSESS CVS'/RESP NURTITIONAL STATUS FBC UEC LFT COAGS LFT and ABG if resp dieasse and OLV
PERIOP
Pre op Nutrition
IAL CVC Temp
Technique:
GA DLT
EPIDURAL
ACTIVE Warming
Multilevel = changing positions
- recheck airway after moving
- long surgery - fluid and blood loss
- manipulation of mediasinal structures = decreased CO and arrthymias
POST OP
ICU
May remain intubated
Analgesia ( difficult - multiple dermatomes)
Physio, VTE. NNutrition
Wait for D3 anastomosis leak
Resp complications , CVS arrthymias, VTE/PE, anastomosis leak, chylothorax, Sepsis
WHIPPLES
SURGERY
OPEN or ROBOTIC
LONG
HEAD UP/ LATERAL - Decreased Preload
Induction:
IAL + CVC + Thoracic Epidural
ETT
Intraoperative Complications
Hypovolaemia - large fluid losses , potential large blood
Hypothermia - active warming
Hyperkalaemia - surgical manipulation lead to PV or HAD obstruction and hepatic ischaemia, intracellular potassium leak
Hypo/Hypreglycaemia - esp if insulinoma (glucose infusion)
Hypoxia - atelectasis
Renal dysfunction - hepatorenal syndrome, monitor urine output.
Post op
THE USUAL + POST OP DIABETES
PHAEOCHROMOCYTOMA
Catecholamine secreting tumour of chromaffin tissue
Usually benign. may be malignant, solitary or multiple.
Most common adrenal but can exist paraganglionic sites base of bladder to base of skull
13% assc with MEN Type 2 - 2A thyroid/parathyroid or 2B Marfan like features with mucosal neuroma
PATIENTS HTN (may be paroxysmal or continuous) Headache Sweating CVS - arrthymias, cardiomyopathy Hyperglycaemia and glycosuria
Dx 24hr meta nephrines. CT/MRI
PREOP
Alpha and Beta blockade (reduces mortality)
Doesnt prevent release but blunts response
phenoxybenzamine 10mg BD - titrated. BP <140. HR <100.
Restore normal circulating volume.
Need 7-10 days of established blockade
Cease phenoxybenzamine the night before
INTRAOP
- CVS - HTN - SNP , Hypo Adrenaline, Norad, Tachy Metoprolol
- Increasing with manipulation, hypotension once resected.
Avoid histamine releasing drugs
POSTOP
ICU
BP - monitor - usually stabilises quickly
Glucoes - hypoglycaemia possible - loss of catecholamines
Steriods - if bilateral adrenalectomy
Analgesia
NEPHRECTOMY
TUMOUR (RCC 90%) -smokers
TRAUMA
OPEN/LAP/ROBOT
PREOP
- associated conditions - anaemia, resp disease, paraneoplastic, HTN Ca
- CVS/RESP
- Renal Injury
- Crossmatch blood
INTRA OP
POSITION - LATERAL , BENT > VQ
BLOOD LOSS
PNEUMOTHORAX - possible
Avoid Nephrotoxics
POST OP
PPC - Analgesia, Physio
PROSTATECTOMY
OPEN VS ROBOT
PREOP
PATIENT FACTORS
- if open epidural
PERIOP
If ROBOT –> access, steep down, long, oedema
POST OP
Ward
TURP
ISSUES
GA VS REGIONAL (Pt, Volume Prostate, Time)
TURP Syndrome (including post op)
Renal Function
Increased morbidity - time >90mins, >45g > 80yo
ANEURYSM
COILING VS CLIPPING WFNS Grade Intubated already IAL - Nimodipine SBP <160mmHg MAP <110, CPP 60-70 Check ECG. Cardiac Function
Careful Induction - Propofol/REMI
CO2 35-40, normal temp, normal glycaemia
POSITIONING
POTENTIAL RUPTURE PLANNING
POST OPERATIVE
